What NOT to say to people in a psychiatric ward

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From Luke’s Journal October 2023  |  Vol.28 No.3  |  Mental Health I

This year, in my early 50s, I was diagnosed with bipolar disorder with hypomania.  This resulted in a three week psychiatric admission to sort out medications. 

Sound scary? Actually, it was quite fun – no housework, delicious healthy food, daily psychological education, exercise programs led by passionate exercise physiologists, hit-and-giggle hydro-volleyball, yoga, relaxation, and we could even explore our creative side in art therapy. With hypomanic enthusiasm, I bounced around doing everything – I even learnt to loom my first beanie. Frankly, it was more like a health spa!

Since this was a private (not public) psychiatric hospital, there were no involuntary psychotic, overtly suicidal or dangerous patients.  There was a mixture of fascinating, colourful, funny, kind, sad, bristly, confused, hurt, lonely, connected, but all beautiful people  – and sometimes the only difference between the staff and the patients, was that the staff wore uniforms (😊).  I realise a positive hospital retreat is not universal, and my insights are derived from a very limited experience (including blunders) with this clientele.

Here are my tips on what NOT to say to people in a psychiatric ward, not as their therapist, but as an equally broken person.

1. “What are you in for?”

It was not a prison, and we were not doing time for crime!!  On admission, we were told NOT to ask each other about our diagnoses.  We were not in hospital as therapists, no matter what our professional backgrounds (including one doctor (me), psychiatric nurses, and psychologists).  We were there to recuperate and recover. 

Mental health is a private matter and only the therapist has permission to ask about it

Having said that, most of us volunteered to talk about our mental health anyway.  Couldn’t help it.  But it was our choice.

2. “How are you?”

This question will inevitably elicit the response: “Good.  How are you?”  Even a depressed patient will say they are ‘good’. It is more of a greeting that has become synonymous with ‘Hello’.  It is not a harmful question, but it usually won’t elicit a meaningful response.

Better questions:

Did you sleep OK last night?

This was our standard morning greeting and gave us a more honest answer, eg. “Terrible!  I could not sleep because I was so upset.  I even used up my maximum amount of prn (pro re nata, or ‘as needed’) tranquillisers– the nurse said it was enough to knock out an elephant!”

We were taught in medical school that an open question would invite a real response and a closed question would shut down the conversation.  With my fellow patients, I found the opposite was true.  The open question is too big, broad and scary. The closed question can be a safe caring probe that invites an easier, concrete, more manageable answer.

Sleep is the universal screening litmus test of someone’s mental state.  Waking up feeling refreshed is the ideal Sabbath rest.  Too much, too little, broken sleep, early morning awakening, nightmares or vivid dreams will tell you more than, “How are you?” 

What’s been happening?

This is a safe question that can just be about physical events rather than upsetting feelings.

Are you ok? 

It is the famous question to check in with potentially suicidal people.  This safe closed question, answered with a single word, can summarise a world of pain, opening up a secure place to elaborate.

3. “How does that make you feel?”

This question undermines counselling 101.  Nobody controls your feelings, except you.  No one can MAKE you feel anything. 

I was really frustrated when my in-patient psychologist repeated this question several times in our first session together. I wanted to organise a new psychologist on discharge and asked for recommendations.  

He replied, “How does that make you feel?” 

That really threw me, as I was in my ‘evolved cortical adult brain’ space.  All I wanted was a piece of relevant information.  His question became his refrain.

“What is the purpose of these psychology sessions in the hospital?  “How does that make you feel?”

“Who helps me make a discharge plan for follow-up?”  “How does that make you feel?”

“When will I know that I am ready for discharge?”  “How does that make you feel?”

“NOW I am feeling really frustrated, and I want to punch you in the head!!!!”  

Withholding information is a form of condescending control in a power imbalance.  Psychology should help us to understand our feelings and motivations, by engaging our cortical brain to generate sensible options, so that we can control our primitive survival responses instead of our emotions controlling us.  The aim is NOT to trigger a fight/ flight/ fold/ freeze response!!!

What are the “Dos” in this situation?

• If someone asks you a reasonable question (and it is not a question that he/she can possibly work out for themselves), then ANSWER THE BLEEPING QUESTION!!  Don’t deliberately withhold information and education.
• Then, if relevant, you may ask something like, “How are you feeling about discharge?”
• Don’t force someone to talk about their feelings.  Ask permission. 

E.g. “You look a bit upset and angry – like you want to punch someone. Would you like to talk about it?”

4.“I know exactly how you feel…”  “You must be feeling….”

These openings sound patronising.  Just because you might have the same DSM-V classification, does NOT mean you know someone else’s feelings.  You are not a mind or emotions reader.  You do not have the same genetics and you have not lived their life experiences. You might have some commonality, but your experiences will not be exactly the same. Don’t “ASSUME” (it will indeed make an ASS out of U and ME).

If you listen through your baggage, your empathy has gone on holidays.  Deny yourself, pick up your rainbow-tagged baggage from the life carousel, then follow them on their journey to find their seemingly-identical blue luggage.

Of course, it is helpful to share common struggles to empathise with your fellow patient.  Show compassion and understanding, not pity.  Listen with intention, affirming their feelings without judgement and without advice.  Reflect and clarify their story before you jump in with your own story. Then you might say something like: “When blah blah happened to me, I felt blah blah.  Is that similar to what you felt when blah blah?” Invite them to connect with your story, which may help them feel that they are not alone, and that you do understand.

Learn from their story.  Don’t be arrogant and think that someone with a mental illness has nothing to teach.  In fact, if you ask their advice or opinion, that will show them that you affirm their own experiences.

Another patient shared these brilliant metaphors for bipolar disorder, which resonated with me.

• “You are like Icarus – exhilarated and flying high.  But when you fly too close to the sun, you end up plummeting.”
• “Mania is like flying in a jet.  The sandbags are the mood stabilisers.  You eventually have to land the plane, and that is always accompanied by a lot of turbulence.
• “Mania is like being in Van Gogh’s “Starry Night” – everything is swirling in your mind, but no one else can see what you are seeing, and you are on your own.”

She also had a helpful response to my question, “How will I know when I am ready for discharge?” 

“You won’t feel overwhelmed by the little things,” (and she didn’t ask, “How do you feel about that?”)

5. “What happened to you?”

While this is usually a well-meaning question, for those with post-traumatic stress disorder (PTSD), this can be a trigger causing retraumatisation as they access emotional memories to bring them into the forefront of their cognitive awareness.  If they are distressed, you can still express your concern and a willingness to listen, but don’t pry or fish for details.

6. Don’t mention God, our Heavenly Father, Jesus, church or hell

While “Jesus loves you” is the most important truth that they need to hear, what they might hear is, “It’s a poor kind of love when you Christians say I am going to burn in hell and send me hate mail and troll my social media to hurl all sorts of insults.  I don’t want to have anything to do with God or Jesus or church or Christians who treat me like that.”

Saying, “Our Father in Heaven loves you” may trigger horrible memories of abusive fathers.

“Creator of the Universe” seems to be a phrase that doesn’t cause offence.  I told a few people, “The Creator of the Universe made you in his image.  You are precious and amazing!!”  That was usually appreciated and did not elicit any distress.

7. “Don’t touch my BLEEP##ING washing!“

Most of the stressors of day-to-day life were removed – we didn’t have to shop, cook, wash the dishes, mop, scrub the toilet, de-mould the shower, empty the garbage, work or plan the day.  We didn’t have to wash our sheets, or the mountain of wet towels and bathrobes generated from the hydrotherapy pool.

Our single personal chore was to wash our own clothes.  The system involved writing your name in a timeslot for the washing machine and dryer.  The washing police patrolled the corridors to enforce the unspoken rules:

• Don’t put your clothes in the wash if your name is not on the official timetable. 
• Take your washing out as soon as it’s finished – others are waiting.
• The ultimate crime: If it’s in the machine beyond the scheduled time, don’t touch my BLEEP##ING washing!  This was considered a boundary violation that warranted the amputation of your hands.  Use the acceptable options of finding the washing owner or ask the nurse to remove the washing.

The topic of laundry became a persistent stain at the staff-patient meetings.  Life’s angst was lint-filtered through the microcosm of a top loader.  Like most silly domestic disputes, the emotional intensity was not really about the washing timetable. It was the drain outlet for airing the inner dirty laundry.  It was the fight response protecting previously breached personal boundaries with a ‘delicates’ bag.  I suspect it was also about having some control in a small area, when life seemed overwhelming (remember the toilet paper response to COVID-19?).

DON’T make an idol out of fresh undies or you will be caught in a spin cycle of relational sacrifice. If you are upset about grubby garbs, instead of yelling baptised expletives, push the PAUSE button.  Power down.  Open the door – have you overloaded?  Take a walk. Hug a tree. Stick your head in an ice bucket. Be thankful for washing machines, rather than scrubbing by hand with a rock in a dirty river.  Whatever you need to do to rebalance the drum.   

Make sure you ask Jesus to cleanse your angry heart, because you cannot wash away your anger on your own.  Take the log out of your own eye, and then you can take the speck out of his eye. When the adult cortical brain has returned, you can gently ask, “Could you please let me know when my washing is finished?  Or ask the nurse to take out my washing?”  Maybe later you can reflect on what was clogging the sink.

If you are on the receiving end of a tirade about washing, remember that the tirade is probably more about the hidden stains on their undergarments. The expletives aren’t swearing – THEY’RE JUST EMPHASIS!  Don’t get defensive.  If you can calmly apologise for your misdemeanour, try not to repeat it and that will soften the fabric of dispute.

James 1:19-20: Know this, my beloved brothers: let every person be quick to hear, slow to speak, slow to anger; for the anger of man does not produce the righteousness of God.

DON’T SAY…	DO SAY…
What are you in for?	Mental health is private.  Let them volunteer information.
How are you?	“What’s been happening?” “Are you sleeping ok?” “Are you ok?”
How does that make you feel?	Answer a genuine factual question. If relevant, you can ask, “How are you feeling about that?” or “You look….upset/ angry/frustrated/ sad. Would you like to talk about it?”
I know exactly how you feel… You must be feeling…	Empathise, listen, reflect, clarify first. Share similar experiences but never assume.
What happened to you?	Express concern and willingness to listen, but don’t pry. “You don’t need to talk about it with me”.
God / Heavenly Father/ Jesus/ church/ hell	“You are made in the image of the Creator of the Universe. Therefore, you are precious and valuable.”
Don’t touch my BLEEPING washing!	Respect boundaries. Be slow to anger. Don’t be offensive or offended. Identify your own triggers.  Take the log out of your own eye.

My final parting words to the ward: “Why is a psychiatric ward like a toilet?”

“Because it’s a safe haven to dump your shit, where your privacy is respected, but you eventually have to come out.”

A bit like praying to God…

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